Beyond VEGF: Angiopoietin-Tie Signaling Pathway in Diabetic Retinopathy.

Complications from diabetic retinopathy such as diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR) constitute leading causes of preventable vision loss in working-age patients. Since vascular endothelial growth factor (VEGF) plays a major role in the pathogenesis of these complications, VEGF inhibitors have been the cornerstone of their treatment. Anti-VEGF monotherapy is an effective but burdensome treatment for DME. However, due to the intensive and burdensome treatment, most patients in routine clinical practice are undertreated, and therefore, their outcomes are compromised. Even in adequately treated patients, persistent DME is reported anywhere from 30% to 60% depending on the drug used. PDR is currently treated by anti-VEGF, panretinal photocoagulation (PRP) or a combination of both. Similarly, a number of eyes, despite these treatments, continue to progress to tractional retinal detachment and vitreous hemorrhage. Clearly there are other molecular pathways other than VEGF involved in the pathogenesis of DME and PDR. One of these pathways is the angiopoietin-Tie signaling pathway. Angiopoietin 1 (Ang1) plays a major role in maintaining vascular quiescence and stability. It acts as a molecular brake against vascular destabilization and inflammation that is usually promoted by angiopoietin 2 (Ang2). Several pathological conditions including chronic hyperglycemia lead to Ang2 upregulation. Recent regulatory approval of the bi-specific antibody, faricimab, may improve long term outcomes in DME. It targets both the Ang/Tie and VEGF pathways. The YOSEMITE and RHINE were multicenter, double-masked, randomized non-inferiority phase 3 clinical trials that compared faricimab to aflibercept in eyes with center-involved DME. At 12 months of follow-up, faricimab demonstrated non-inferior vision gains, improved anatomic outcomes and a potential for extended dosing when compared to aflibercept. The 2-year results of the YOSEMITE and RHINE trials demonstrated that the anatomic and functional results obtained at the 1 year follow-up were maintained. Short term outcomes of previously treated and treatment-naive eyes with DME that were treated with faricimab during routine clinical practice suggest a beneficial effect of faricimab over other agents. Targeting of Ang2 has been reported by several other means including VE-PTP inhibitors, integrin binding peptide and surrobodies.

Early-Phase Perceptions of COVID-19's Impact on Ophthalmology Practice Patterns: A Survey from the Pan-American Association of Ophthalmology.

Purpose: The COVID-19 pandemic affected medical practice worldwide due to interventions to prevent spreading. Its effect on ophthalmology practices in Latin America has not yet been explored. We aimed to assess the perceptions about the pandemic from countries' ophthalmological national and subspecialty retina societies affiliated to the Pan-American Association of Ophthalmology (PAAO). Patients and Methods: A survey-based study of leaders of national ophthalmological and retinal societies was conducted. The survey was sent by email to 30 societies, from which 20 responded (12 countries, 66.6% response rate). It included closed- and open-ended questions about (1) operational capacity and precautions, (2) telemedicine and virtual care, (3) procedures, and (4) post-pandemic considerations. Results: There was a marked decline in ophthalmology patient visits (80-95%) and elective surgeries (90%) during 2020 compared to before the pandemic. Precautions like temperature checks, mask usage, and social distancing were widely implemented while personal protective equipment (PPE) availability varied. Telemedicine use was limited due to lack of experience with it. Reopening plans focused on maintaining precautions and gradually resuming activities. Economic and security concerns were raised, and adherence to guidelines was emphasized. Respondents acknowledged the need to adapt to a "new normal". Long duration drugs, fewer imaging studies, and shorter wait times were preferred; however, availability of long duration drugs was limited. Conclusion: The pandemic impacted ophthalmology in Latin America, with reduced patient visits, procedures, and surgeries. Delayed treatment and complications were likely the result of the pandemic.

Five-year outcomes after intravitreal bevacizumab of treatment-naive eyes with macular edema secondary to CRVO in routine clinical practice: Results of the Pan-American Collaborative Retina Study (PACORES) group.

PURPOSE: The purpose of this study was to report the 5-year outcomes of treatment-naive eyes with cystoid macular edema secondary to central retinal vein occlusion treated with intravitreal bevacizumab in routine clinical practice. METHODS: We conducted multicenter retrospective non-comparative case series of 102 eyes. The main outcome measured was the change in best-corrected visual acuity (BCVA) at 5 years. Secondary outcomes included the number of injections and the change in CMT at 5 years. RESULTS: At 5 years, the mean BCVA improved from 1.22 ± 0.58 (Snellen 20/428) at baseline to 1.00 ± 0.68 logMAR (Snellen 20/200; p < 0.0001). At 5 years, 48 (47%) eyes had a gain of ≥ 3 lines, 41 (40.2%) eyes remained within 3 lines and 13 (12.7%) eyes had a loss of ≥ 3 lines of BCVA. The CMT improved from 740 ± 243 to 322 ± 179 µm (p < 0.0001). At 5 years, 59 (57.8%) eyes had a completely dry SD-OCT. Patients received a total of 10.6 ± 6.1 (range 6-27) injections. Baseline BCVA (p < 0.0001) and the duration of symptoms prior to initial anti-VEGF injection (p = 0.0274) were the only predictive factors for BCVA at 5 years. CONCLUSIONS: After 5 years with an average of 10.6 injections, there was a mean gain of 0.22 logMAR. In addition, more eyes achieved a BCVA of ≥ 20/40, gained ≥ 3 lines and less patients had a BCVA ≤ 20/200. Eyes with a better baseline BCVA and a shorter duration of symptoms were more likely to achieve better BCVA at 5 years.

Adjunctive serial post-operative intravitreal methotrexate injections in the management of advanced proliferative vitreoretinopathy.

PURPOSE: To assess the effects of weekly post-operative intravitreal methotrexate injections on eyes with grade C proliferative vitreoretinopathy (PVR) that underwent surgical repair. METHODS: Retrospective case-control study of 16 eyes with retinal detachment and grade C PVR. Seven eyes received weekly intravitreal MTX injections post-operatively as an adjunct and 9 eyes served as the control. The main outcome measure was the retinal re-attachment rate. RESULTS: In the MTX group, 86% (6/7) of eyes had a complete retinal re-attachment at the end of the follow-up period. In contrast in the no MTX group, only 22.2% (2/9) of eyes had a complete retinal re-attachment (p = 0.0406). The patients in the MTX group received a mean of 6 injections (range 4-8). There were no cases of corneal epitheliopathy. CONCLUSIONS: Serial intravitreal MTX as an adjunct to surgical repair holds promise for the management of PVR.

Incidencia de complicaciones intra y posoperatorias en pacientes geriátricos durante la cirugía abdominal mayor electiva / Incidence of intraoperative and postoperative complications in geriatric patients during major elective abdominal surgery

Introducción: El aumento de la expectativa de vida determina un incremento en la incidencia de enfermedades con indicación quirúrgica. El avance en las técnicas quirúrgicas, los cuidados intensivos y el conocimiento más profundo del proceso de envejecimiento tiende a favorecer la disminución de la morbimortalidad perioperatoria del paciente geriátrico. Objetivo: Determinar la incidencia de complicaciones intra y posoperatorias en pacientes geriátricos durante la cirugía abdominal mayor electiva. Métodos: Se realizó un estudio observacional descriptivo, de corte transversal a 373 pacientes geriátricos programados para intervención quirúrgica abdominal mayor desde enero de 2017 hasta diciembre de 2019 en el Hospital Clínico Quirúrgico Dr. Miguel Enríquez. Se registró la incidencia de complicaciones perioperatorias relacionándolas con las variables de estudio. Resultados: Las complicaciones más frecuentes fueron las cardiovasculares. La mortalidad fue escasa. Conclusiones: Las complicaciones perioperatorias detectadas en los pacientes geriátricos estudiados, se relacionan con las enfermedades previas, el tipo y la envergadura de la cirugía y con el tiempo quirúrgico(AU)

Introduction: The increase in life expectancy determines an increase in the incidence of diseases with surgical indication. Advances in surgical techniques, intensive care and deeper understanding of the aging process tend to favor the reduction of perioperative morbidity and mortality among geriatric patients. Objective: To determine the incidence of intraoperative and postoperative complications among geriatric patients during elective major abdominal surgery. Methods: A descriptive, cross-sectional and observational study was carried out with 373 geriatric patients scheduled for major abdominal surgery from January 2017 to December 2019 at Dr. Miguel Enríquez Clinical-Surgical Hospital. The incidence of perioperative complications was recorded, relating them to the study variables. Results: The most frequent complications were the cardiovascular ones. Mortality was low. Conclusions: The perioperative complications identified among the geriatric patients studied are related with previous diseases, with the type and extent of surgery, and with the surgical time(AU)

Utilidad del ondansetrón vs dexametasona como profilaxis antiemética posoperatoria durante la cirugía mayor ginecológica / Usefulness of ondansetron versus dexamethasone as postoperative antiemetic prophylaxis during major gynecologic surgery

Introducción: Las náuseas y vómitos posoperatorios son una secuela no deseada durante la etapa de recuperación anestésica. Objetivo: Evaluar la utilidad de la dexametasona en comparación con el ondansetrón para la prevención de las náuseas y vómitos posoperatorios después de procedimientos quirúrgicos ginecológicos mayores, bajo anestesia general orotraqueal. Método: Se realizó un estudio observacional analítico, prospectivo, en 84 pacientes mayores de 19 años, en el Hospital Clínico Quirúrgico Miguel Enríquez desde octubre de 2018 hasta septiembre de 2019, divididas de forma secuencial, en orden de llegada a la unidad quirúrgica, en dos grupos. Al grupo 1 se le administró dexametasona (4 mg endovenosa); al grupo 2 (4 mg de ondansetrón), 30 min antes de finalizar la cirugía. Resultados: Predominó de forma significativa el riesgo medio de náuseas y vómitos posoperatorios en los pacientes con edades comprendidas entre 41 y 50 años. Predominó la condición de excelente y buena (pgt;0,05) en cuanto a la efectividad del tratamiento profiláctico. La cefalea prevaleció de forma significativa en el grupo 2. La mayor parte de las pacientes no presentó eventos adversos. Conclusiones: El ondansetrón y la dexametasona son útiles para la profilaxis de las náuseas y vómitos posoperatorios en pacientes intervenidas de cirugía mayor ginecológica, bajo anestesia general orotraqueal por lo que se considera un tratamiento seguro, con eventos adversos leves y de fácil control(AU)

Introduction: Postoperative nausea and vomiting are an unwanted sequel during the anesthetic recovery stage. Objective: To evaluate the usefulness of dexamethasone compared with ondansetron for the prevention of postoperative nausea and vomiting after major gynecological surgical procedures, under general orotracheal anesthesia. Method: A prospective, analytical and observational study was carried out with 84 patients older than 19 years of age, at Miguel Enríquez Hospital Clinical-Surgical Hospital, from October 2018 to September 2019, divided sequentially, in order of arrival at the surgical unit, into two groups. The group 1 was administered dexamethasone (4 mg intravenously), and the group 2 was administered ondansetron (4 mg), 30 min before the end of the surgery. Results: The average risk of postoperative nausea and vomiting prevailed significantly among patients aged 41-50 years. Excellent and good conditions predominated (pgt;0.05) in terms of effectiveness of prophylactic treatment. Headache prevailed significantly in the group 2. Most of the patients did not present adverse events. Conclusions: Ondansetron and dexamethasone are useful for postoperative nausea and vomiting prophylaxis among patients who received major gynecological surgery, under general orotracheal anesthesia, a reason why it is considered a safe treatment, with mild adverse events and easy control(AU)

Yellow (577 nm) micropulse laser versus half-dose verteporfin photodynamic therapy in eyes with chronic central serous chorioretinopathy: results of the Pan-American Collaborative Retina Study (PACORES) Group.

PURPOSE: To compare the functional and anatomical outcomes of eyes with chronic central serous chorioretinopathy treated with yellow micropulse (MP) laser versus half-dose verteporfin photodynamic therapy (PDT). METHODS: This is a multicentre, retrospective comparative study of 92 eyes treated with yellow MP laser (duty cycle of 5%, zero spacing between spots, spot size varied from 100 to 200 µm, power varied from 320 to 660 mW, and the pulse burst duration was 200 ms) and 67 eyes treated with PDT (half-dose verteporfin (3 mg/m2) infused over 10 min), followed by laser activation for 83 s. Spot sizes varied from 400 to 2000 µm. RESULTS: In the MP group, at 12 months of follow-up, the mean best corrected visual acuity (BCVA) improved from the logarithm of the minimum angle of resolution (logMAR) of 0.41±0.27 at baseline to 0.21±0.26 (P<0.0001), 48.9% (45/92) of eyes had an improvement of ≥3 lines of BCVA from baseline, 48.9% (45/92) of eyes remained within 2 lines of baseline BCVA, and only 2.2% (2/92) of eyes lost ≥3 lines of BCVA from baseline. In the PDT group, at 12 months of follow-up, the mean BCVA changed from logMAR of 0.50±0.34 at baseline to 0.47±0.34 (P=0.89), 19% (13/67) of eyes had an improvement of ≥3 lines of BCVA from baseline, 73% (49/67) of eyes remained within 2 lines of baseline BCVA, and 7% (5/67) of eyes lost ≥3 lines of BCVA from baseline. There were no adverse events attributable to the yellow MP laser treatment. One eye in the PDT group developed choroidal neovascularisation, which was treated with three intravitreal bevacizumab injections. CONCLUSIONS: Both PDT and MP are effective in restoring the macular anatomy. In places where PDT is not available, yellow MP laser may be an adequate treatment alternative.

Un-explained visual loss following silicone oil removal: results of the Pan American Collaborative Retina Study (PACORES) Group.

PURPOSE: To report the incidence and clinical features of patients that experienced un-explained visual loss following silicone oil (SO) removal. METHODS: Multicenter retrospective study of patients that underwent SO removal during 2000-2012. Visual loss of ≥2 lines was considered significant. RESULTS: A total of 324 eyes of 324 patients underwent SO removal during the study period. Forty two (13%) eyes suffered a significant visual loss following SO removal. Twenty three (7.1%) of these eyes lost vision secondary to known causes. In the remaining 19 (5.9%) eyes, the loss of vision was not explained by any other pathology. Eleven of these 19 patients (57.9%) were male. The mean age of this group was 49.2 ± 16.4 years. Eyes that had an un-explained visual loss had a mean IOP while the eye was filled with SO of 19.6 ± 6.9 mm Hg. The length of time that the eye was filled with SO was 14.8 ± 4.4 months. In comparison, eyes that did not experience visual loss had a mean IOP of 14 ± 7.3 mm Hg (p < 0.0002) and a mean tamponade duration of 9.3 ± 10.9 months (p < 0.0001). CONCLUSIONS: An un-explained visual loss after SO removal was observed in 5.9% of eyes. Factors associated with this phenomenon included a higher IOP and longer SO tamponade duration.

ANATOMICAL AND FUNCTIONAL OUTCOMES OF SYMPTOMATIC IDIOPATHIC VITREOMACULAR TRACTION: A Natural History Study From the Pan American Collaborative Retina Study Group.

PURPOSE: To describe the natural history of eyes with symptomatic idiopathic vitreomacular traction (VMT). METHODS: Retrospective multicenter study of 168 eyes with spectral-domain optical coherence tomography (SD-OCT) findings consistent with idiopathic VMT. All eyes were graded according to SD-OCT findings. Grade 1 was defined as incomplete cortical vitreous separation with foveal attachment. Grade 2 was defined as Grade 1 plus intraretinal cysts or clefts. Grade 3 was defined as Grade 2 plus a foveal detachment. All patients were followed for at least 6 months. RESULTS: There were 168 patients (51 men) with a mean age of 68.8 ± 10.7 years. Patients were followed for a mean of 22.7 ± 20.1 months. The mean duration of symptoms before the initial presentation was 3.65 ± 5.42 months. At baseline, 72 eyes had Grade 1, 74 eyes had Grade 2, and 22 eyes had Grade 3 SD-OCT findings. Over the follow-up period, 36 eyes (21.4%) had spontaneous resolution of the VMT with normalization of the foveal anatomy. The mean time to resolution was 12.3 ± 12.6 months. An unfavorable anatomical outcome occurred in 7.7% (13 of 168) of the eyes, with 6 eyes developing a lamellar macular hole and 7 eyes developing a full-thickness macular hole. This occurred at a mean of 10.3 ± 10.7 months after the presentation. Subgroup analysis based on baseline SD-OCT grade showed that 4.1% (3 of 73) of Grade 1 eyes compared with 6.8% (5 of 74) of Grade 2 eyes, and 23.8% (5 of 21) of Grade 3 eyes developed a full-thickness macular hole or lamellar macular hole (P = 0.0109, chi-square test). In the remaining 119 eyes, at the last follow-up, 65 eyes had Grade 1, 42 eyes had Grade 2, and 12 eyes had Grade 3 VMT. On average, the best-corrected visual acuity improved from 0.40 ± 0.35 logarithm of the minimum angle of resolution (Snellen, 20/50) at baseline to 0.35 ± 0.36 logarithm of the minimum angle of resolution (Snellen, 20/45; P = 0.0372), and the mean central macular thickness improved from 350 ± 132 µm to 323 ± 121 µm. CONCLUSION: Spontaneous resolution of VMT occurred in 21.4% (36 of 168) of eyes after a mean follow-up of 11.4 ± 12.6 months. An unfavorable anatomical outcome occurred in 7.7% (13 of 168) of eyes. The baseline SD-OCT grade may predict the progression to full-thickness macular hole.

Neoplasia escamosa de la superficie ocular en pacientes con pterigión en Perú / Squamous neoplasia of the ocular surface in patients with pterygium in Peru

Objetivos. Estimar la frecuencia de neoplasia escamosa de la superficie ocular (NESO) no sospechada en pterigión, la precisión del diagnóstico clínico y las características demográficas y clínicas asociadas. Materiales y métodos. Se examinaron los informes histopatológicos de los pacientes con diagnóstico clínico de pterigión y/o NESO que fueron quirúrgicamente tratados entre marzo de 2009 y diciembre de 2012 en el Instituto Nacional de Oftalmología en Lima, Perú. La precisión del diagnóstico clínico para identificar la NESO se evaluó mediante la sensibilidad, especificidad y los cocientes de probabilidad. Se realizaron modelos de regresión log-log negativos para identificar las características demográficas y clínicas asociadas con un aumento de las probabilidades de diagnosticar NESO. Resultados. Se examinaron 3021 informes de histopatología. La frecuencia de NESO no sospechada en pterigión fue de 0,65%. El diagnóstico clínico presentó una sensibilidad del 85%, una especificidad del 99%, un cociente de probabilidad positiva de 111,89 y un cociente probabilidad negativa de 0,15. Las características asociadas fueron el sexo masculino (OR 1,15; IC 95%:1,01-1,30), pacientes de 61 a 80 años (OR 1,54; IC 95%: 1,28-1,85), ≥ de 81 años (OR 3,10; IC 95%: 2,09-4,58), pacientes con lesiones recurrentes (OR 1,59; IC 95%: 1,03-2,46) y lesiones en el lado temporal (OR 3,57; IC 95%: 2,63-4,85) presentaron mayor probabilidad de NESO. Conclusiones. Se encontró una baja frecuencia de NESO no sospechada, sin embargo, es recomendable realizar el estudio histopatológico de forma rutinaria para evitar diagnósticos erróneos de NESO como pterigión.

Objectives. To estimate the frequency of unsuspected ocular surface squamous neoplasia (OSSN) in pterygium, the accuracy of clinical diagnosis, and associated demographic and clinical characteristics. Materials and methods. We reviewed histopathological reports of patients with a clinical diagnosis of pterygium and/or OSSN who were surgically treated between March 2009 and December 2012 at the National Eye Institute in Lima, Peru. The accuracy of the clinical diagnosis of OSSN was assessed by sensitivity, specificity, and likelihood ratios. Models of negative log-log regression were performed to identify demographic and clinical characteristics associated with increased odds of diagnosing OSSN. Results. 3,021 histopathological reports were reviewed. The frequency of unsuspected OSSN in pterygium was 0.65%. Clinical diagnosis had a sensitivity of 85%, a specificity of 99%, a positive likelihood ratio of 111.89, and a negative likelihood ratio of 0.15. Associated characteristics were male gender (OR =1.15; 95% CI: 1.01 to 1.30), age group of 61- 80 years (OR = 1.54, 95% CI: 1.28 to 1.85) ≥ 81 years (OR = 3.10; 95% CI: 2.09 to 4.58), presence of recurrent lesions (OR = 1.59; 95% CI: 1.03 to 2.46) and temporal location lesions (OR = 3.57; 95% CI: 2.63 to 4.85). These characteristics were associated with a greater likelihood of OSSN. Conclusions. A low frequency of unsuspected OSSN was found; however, it is recommended to routinely perform histopathology studies to avoid misdiagnosis of OSSN as pterygium.

Intraocular pressure elevation after uncomplicated pars plana vitrectomy: results of the Pan American Collaborative Retina Study Group.

PURPOSE: To compare the incident rates of sustained elevation of intraocular pressure (IOP) after uncomplicated pars plana vitrectomy for idiopathic epiretinal membrane and the unoperated fellow eye. METHODS: Retrospective multicenter study of 198 patients who underwent pars plana vitrectomy for an idiopathic epiretinal membrane that was followed for at least 12 months. The diagnosis of sustained IOP elevation was defined as an elevation of IOP ≥ 24 mmHg or an increase of ≥ 5 mmHg in the IOP from baseline on 2 separate visits that warranted the initiation of ocular hypotensive therapy. The main outcome measured was the development of sustained IOP elevation as defined above. RESULTS: Patients were followed for an average of 47.3 ± 24 months (range, 12-106 months). In the vitrectomized eyes, 38 of the 198 (19.2%) patients developed elevated IOP compared with 9 of the 198 (4.5%) unoperated fellow eyes (P < 0.0001, Fisher exact test; odds ratio, 4.988). Possible risk factors include a family history of open-angle glaucoma (P = 0.0004 Fisher exact test; odds ratio, 7.206) and cataract surgery (P = 0.0270 Fisher exact test; odds ratio, 2.506). CONCLUSION: Uncomplicated PPV seems to increase the IOP, particularly in those who are pseudophakic and have a family history of open-angle glaucoma. This increase in IOP may lead to glaucomatous damage if not managed appropriately. Patients with a previous PPV need to be followed by an ophthalmologist to monitor the IOP in the vitrectomized eye.

[Squamous neoplasia of the ocular surface in patients with pterygium in Peru]. / Neoplasia escamosa de la superficie ocular en pacientes con pterigión en Perú

OBJECTIVES: To estimate the frequency of unsuspected ocular surface squamous neoplasia (OSSN) in pterygium, the accuracy of clinical diagnosis, and associated demographic and clinical characteristics. MATERIALS AND METHODS: We reviewed histopathological reports of patients with a clinical diagnosis of pterygium and/or OSSN who were surgically treated between March 2009 and December 2012 at the National Eye Institute in Lima, Peru. The accuracy of the clinical diagnosis of OSSN was assessed by sensitivity, specificity, and likelihood ratios. Models of negative log-log regression were performed to identify demographic and clinical characteristics associated with increased odds of diagnosing OSSN. RESULTS: 3,021 histopathological reports were reviewed. The frequency of unsuspected OSSN in pterygium was 0.65%. Clinical diagnosis had a sensitivity of 85%, a specificity of 99%, a positive likelihood ratio of 111.89, and a negative likelihood ratio of 0.15. Associated characteristics were male gender (OR =1.15; 95% CI: 1.01 to 1.30), age group of 61-80 years (OR = 1.54, 95% CI: 1.28 to 1.85) ≥ 81 years (OR = 3.10; 95% CI: 2.09 to 4.58), presence of recurrent lesions (OR = 1.59; 95% CI: 1.03 to 2.46) and temporal location lesions (OR = 3.57; 95% CI: 2.63 to 4.85). These characteristics were associated with a greater likelihood of OSSN. CONCLUSIONS: A low frequency of unsuspected OSSN was found; however, it is recommended to routinely perform histopathology studies to avoid misdiagnosis of OSSN as pterygium.

Intravitreal tumor necrosis factor-alpha inhibitors for neovascular age-related macular degeneration suboptimally responsive to antivascular endothelial growth factor agents: a pilot study from the Pan American Collaborative Retina Study Group.

PURPOSE: To compare the short-term visual and anatomic outcomes after intravitreal injections of 2 different tumor necrosis factor-α inhibitors to continued antivascular endothelial growth factor (VEGF) therapy in eyes with choroidal neovascularization (CNV) secondary to age-related macular degeneration that responded suboptimally to anti-VEGF agents. METHODS: Retrospective comparative case series of 26 eyes. Eyes were injected intravitreally with 1 mg infliximab, 2 mg infliximab, 2 mg adalimumab, or 1.25 mg bevacizumab. The main outcomes measured were the best-corrected visual acuity (BCVA) and the central macular thickness (CMT) at 3 months of follow-up. RESULTS: The mean log minimal angle of resolution BCVA changed from 1.04±0.23 at baseline to 1.06±0.51 at 3 months (P=0.9455) in the 1-mg infliximab group; 0.94±0.48 at baseline to 0.85±0.43 in the 2-mg infliximab group (P=0.2802); 1.58±0.50 at baseline to 1.38±0.43 in the adalimumab group (P=0.1116); and 1.08±0.1 at baseline to 1.03±0.16 in the bevacizumab group (P=0.9928). The mean CMT changed from 387±54 µm at baseline to 342±108 µm (P=0.1053) in the 1-mg infliximab group; 301±42 µm at baseline to 284±73 µm (P=0.4854) in the 2-mg infliximab group; remained unchanged at 348±106 µm (P=0.308) in the adalimumab group; and 362±66 µm to 340±27 µm in the bevacizumab group (P=0.4622). Adverse events included uveitis in 37.5% (6/16) of eyes injected with infliximab. CONCLUSION: Intravitreal infliximab and adalimumab do not appear to benefit eyes with CNV that responded suboptimally to anti-VEGF agents. Intravitreal injections of infliximab may elicit a severe intraocular inflammatory reaction.

Intravitreal infliximab for refractory pseudophakic cystoid macular edema: results of the Pan-American Collaborative Retina Study Group.

Inflammation is the major etiologic factor in the development of pseudophakic cystoid macular edema (CME). Several soluble mediators of inflammation such as tumor necrosis factor alpha (TNF-α) have been implicated in the pathogenesis of ocular inflammation. The purpose of this study is to report the short-term visual and anatomic outcomes following intravitreal injections of infliximab in eyes with refractory CME secondary to cataract surgery. An interventional, retrospective study of 7 eyes with refractory CME that were injected with 1 mg of infliximab. The main outcome measures were best-corrected visual acuity (BCVA) and central macular thickness (CMT) at 6-month follow-up. At the 6 month follow-up, BCVA improved from 1.14 ± 0.59 logMAR at baseline to 0.51 ± 0.35 logMAR (p = 0.0156). CMT also improved from 584 ± 159 µm at baseline to 327 ± 127 µm at 6 months (p = 0.0111). No systemic adverse events were reported in these patients. There was a single episode of uveitis that responded to topical steroids. Inhibition of TNF-α may be beneficial in the treatment of refractory pseudophakic CME.

Endophthalmitis after pars plana vitrectomy: results of the Pan American Collaborative Retina Study Group.

PURPOSE: To determine the incidence of endophthalmitis after 20-, 23-, and 25-gauge pars plana vitrectomies (PPVs). METHODS: Retrospective comparative case series of consecutive patients who underwent 20-, 23-, or 25-gauge PPV at 11 centers from Latin America between 2005 to 2009. Pars plana vitrectomy cases were identified through a search of the billing records of each institution. Cases of PPV performed in the management of trauma, endophthalmitis, and combined PPV phacoemulsification cases were excluded. Endophthalmitis was diagnosed by clinical criteria regardless of the microbiologic results. The incidence of post-PPV endophthalmitis was compared between 20-, 23-, and 25-gauge PPVs. RESULTS: A total of 35,427 cases of PPV were identified during the study period (n = 19,865 for 20 gauge, n = 10,845 for 23 gauge, and n = 4,717 for 25 gauge). The 5-year post-PPV endophthalmitis incidence rates were 0.020% (4 of 19,865), 0.028% (3 of 10,845), and 0.021% (1 of 4,717) for 20 gauge, 23 gauge, and 25 gauge, respectively (P = 0.9685). CONCLUSION: Small-gauge transconjunctival PPV does not appear to increase the rates of post-PPV endophthalmitis.

Intravitreal bevacizumab for inflammatory choroidal neovascularization: results from the Pan-American Collaborative Retina Study Group at 24 months.

BACKGROUND: To evaluate the anatomical and functional outcomes of intravitreal bevacizumab (1.25 or 2.5 mg) in the treatment of inflammatory choroidal neovascularization at 24 months. METHODS: We reviewed the clinical records of 22 consecutive patients (23 eyes) with choroidal neovascularization secondary to chorioretinal inflammatory disease in this interventional retrospective multicenter case series. Sixteen eyes (63.6%) received a dose of 1.25 mg of intravitreal bevacizumab, and 7 eyes (36.4%) received a dose of 2.5 mg of intravitreal bevacizumab. RESULTS: At baseline, the mean best-corrected visual acuity was 0.68 logarithm of minimum angle of resolution (Early Treatment Diabetic Retinopathy Study chart = 20/100). After intravitreal bevacizumab, best-corrected visual acuity improved significantly to 0.41 logarithm of minimum angle of resolution (20/51), 0.42 logarithm of minimum angle of resolution (20/53), and 0.40 logarithm of minimum angle of resolution (20/50) at 6, 12, and 24 months, respectively (P < 0.05). Fourteen eyes (60.8%) received 1 injection. Central macular thickness by optical coherence tomography decreased from 375.3 µm (range: 240-634 µm) at baseline to 241.6 µm (range: 189-306 µm) at 24 months of follow-up (P < 0.0001). CONCLUSION: Intravitreal bevacizumab at doses of 1.25 mg and 2.5 mg seems to provide stability or improvement in best-corrected visual acuity, optical coherence tomography, and fluorescein angiogram in inflammatory choroidal neovascularization at 24 months. All patients were treated after the underlying uveitic condition was controlled.

intravitreal tumor necrosis factor inhibitors in the treatment of refractory diabetic macular edema: a pilot study from the Pan-American Collaborative Retina Study Group.

PURPOSE: The purpose of this study was to report the short-term visual and anatomical outcomes after intravitreal injections of two different tumor necrosis factor α inhibitors in eyes with refractory diabetic macular edema. METHODS: An interventional, retrospective, multicenter study of 39 eyes with refractory diabetic macular edema that were injected with adalimumab (n = 5 for 2 mg) or infliximab (n = 15 for 1 mg; n = 19 for 2 mg). The main outcome measures were the best-corrected visual acuity and the central macular thickness at 3 months of follow-up. RESULTS: In the 1-mg infliximab group, the logarithm of the minimal angle of resolution best-corrected visual acuity improved from 1.49 ± 0.58 at baseline to 1.38 ± 0.56 at 3 months (P = 0.6991). In the 2-mg infliximab group, the logarithm of the minimal angle of resolution best-corrected visual acuity worsened from 0.76 ± 0.54 to 1.03 ± 0.69 at 3 months (P = 0.5995). In the adalimumab group, the logarithm of the minimal angle of resolution best-corrected visual acuity improved from 1.44 ± 0.77 to 1.08 ± 0.85 at 3 months (P = 0.2500). The central macular thickness in the 1-mg infliximab group decreased from 459 ± 125 µm at baseline to 388 ± 131 µm at 3 months (P = 0.1178). In the 2-mg infliximab group, the central macular thickness remained unchanged from 378 ± 97 µm at baseline to 349 ± 118 µm at 3 months (P = 0.2162). In the adalimumab group, the central macular thickness remained unchanged from 521 ± 163 µm at baseline to 526 ± 390 µm at 3 months (P = 0.1250). There were no systemic side effects reported in any of the patients. However, laboratory markers for autoimmunity were not done. None of the eyes injected with either adalimumab or 1 mg of infliximab had adverse ocular events. In the 2-mg infliximab group, 42% (8 of 19) of eyes developed severe uveitis. Three of these eyes (37.5%) required pars plana vitrectomy. The uveitis in the remaining five eyes resolved with topical steroid therapy. CONCLUSION: Both intravitreal adalimumab and infliximab do not appear to benefit eyes with refractory diabetic macular edema. Intravitreal injections of infliximab may elicit a severe intraocular inflammatory reaction.

Comparison of two doses of intravitreal bevacizumab as primary treatment for macular edema secondary to central retinal vein occlusion: results of the pan American collaborative retina study group at 24 months.

PURPOSE: The purpose of this study was to compare the injection burden, central macular thickness (CMT), and change in best-corrected visual acuity after injecting 1.25 mg or 2.5 mg bevacizumab as needed in patients with primary macular edema secondary to central retinal vein occlusion. METHODS: This is an interventional, retrospective, comparative multicenter study of 86 eyes with macular edema secondary to central retinal vein occlusion that were treated primarily with intravitreal bevacizumab (44 eyes, 1.25 mg; 42 eyes, 2.5 mg). The main outcome measures were the CMT and the change of best-corrected visual acuity at 24 months. RESULTS: All patients completed at least 24 months of follow-up. The mean number of injections per eye were 7.2 for the 1.25-mg dose group and 8.1 for the 2.5-mg dose group (P = 0.4492). At 24 months, in the 1.25-mg dose group, the logarithm of the minimal angle of resolution best-corrected visual acuity improved from baseline 0.35 +/- 0.57 units (P < 0.0001) versus 0.27 +/- 0.68 units for the 2.5-mg dose group (P < 0.0001). These differences were not statistically significant between both dose groups. In the 1.25-mg dose group, 25 (56.8%) eyes gained >or=3 lines of Early Treatment of Diabetic Retinopathy Study visual acuity and 6 (13.6%) lost >or=3 lines of Early Treatment of Diabetic Retinopathy Study visual acuity. In the 2.5-mg dose group, 24 (57.1 %) eyes improved >or=3 lines of Early Treatment of Diabetic Retinopathy Study visual acuity and 7 (16.7%) lost >or=3 lines of Early Treatment of Diabetic Retinopathy Study visual acuity. The CMT in the 1.25-mg dose group improved from 635 +/- 324 microm to 264 +/- 160 microm (P < 0.0001) versus 528 +/- microm to 293 +/- 137 microm in the 2.5-mg dose group (P < 0.0001). There was no statistically significant difference between both dose groups with regard to the CMT reduction. CONCLUSION: Intravitreal bevacizumab at doses up to 2.5 mg seems to be effective in improving visual acuity and reducing CMT in macular edema secondary to central retinal vein occlusion. There were no statistically significant differences between the two dose groups with regard to the number of injections, CMT, and change in visual acuity.